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Health care in Costa Rica: boom and crisis.
In 1960-1980 Costa Rica experienced a health boom, achieving significant improvements which moved that country into the number two position in Latin America for indicators such as population coverage, infant mortality, life expectancy and health services. In addition, there was a gradual process of integration of health services. But in the same period, the cost of health care as a percentage of GNP increased almost 5-fold and in 1980 was the fourth highest in the region. The economic crisis of the 1980s aggravated the financial difficulties; to cope with them, the government introduced an austere program to reduce costs and plans to transform the current model of health care into a more efficient one capable of maintaining Costa Rica's high health standards in the future. The paper is divided into five sections: summary of the historical development of health care, and description of its current organization and of its gradual process of integration; estimation of population coverage and its trends, evaluation of inequalities in coverage, and identification of the non-covered group; analysis of health-care financing and its sources, as well of the recent financial desequilibrium, its causes and measures to restore the equilibrium; description of health care benefits and their differences among groups and regions, analysis of the country's advances in health-care facilities and standards, and measurement of the impact of the health care system in income distribution; and description of the rising cost of health care and the current crisis, analysis of the causes of both phenomena, and review of the measures that have been and should be implemented to solve these problems.
Changes in health financing: the Chilean experience.
This paper examines the organizational and financial changes experienced by the Chilean Health System in the last 20 years. The succession of widely different political and philosophical views sponsored by the governments of Frei, Allende and Pinochet and the marked economic fluctuations experienced in the last decade have affected the organization of health care financing and the allocation of resources among the population. The trend towards a completely state financed health care system was reversed in 1973. Pinochet's government explicitely included the private sector in the provision of public health services and assigned the State a subsidiary role. Several financing mechanisms created to coopt private capital into the health system are described as well as the evolution of private and public health care expenditures. The political and economic context that shapes the allocation of limited health care resources among a population with a highly unequal income distribution may endanger the access and the quality of health care services in the country.
Health and social inequities in Turkey.
Social and economic policies of governments directly influence the health of the people. These policies, in turn, are determined by the national and foreign controllers of power. Economic and social factors in Turkey during the late 1970s led to a new modelling of the economic system, from a Keynesian to a market-oriented and monetarist model. The state mechanism was also altered to form a centralized, authoritarian regime in order to enforce the requirements of the economy. As a result, the middle class diminished in size, inequalities in income distribution increased, unemployment climbed, the purchasing power of wage earners decreased, government spending for education and health was cut and new oppressive laws were enacted. Health services were already urban-biased and hospital-oriented, but new free-market measures were instituted which promoted private health institutions and attempted to transform state-owned and financed hospitals into self-supporting, independent business enterprises. The only school of public health was closed down; preventive medicine expenditures were lowered while hospital rates and drug prices were increased. All these changes affected the health status of the population. Mortality and morbidity inequalities had already existed between the rich and the poor, men and women, urban and rural settlements, educated and illiterate, West and East, always in favour of the former. However, the new policies exacerbated the inequities. Infectious diseases including tuberculosis increased, nutrition worsened, occupational diseases and work accidents rose to be the highest in Europe. The power-holding minority is not interested in the health of populations and is committed to pursue its social and economic policies. Ad hoc research, especially cross-sectional mortality studies repeated at regular intervals can provide data on the most vulnerable groups as no other valid information exists. There is little hope of these data being used for intervention unless democratic changes take place.
Cultural problems of ageing especially regarding gender and intergenerational equity.
The absence of old age as a specific social group in some cultures raises the question of ageing as a cultural construction. In this paper we will consider only problems of cultural ageing in industrial Western society and especially in some OECD countries. There, demographic changes have been characterised by ageing of populations, visible since the fifties, by feminization of later life and modifications of social network. Ageing of population including the oldest generations have made definitions of later life more politicized and have gone together with new attitudes towards ageing and elderly people giving rise to different patterns of ageism. Examination of incomes, health status, social support of the elderly shows that until today there have been persistent inequalities related to age, gender and social class in terms of resources, access to informal and formal care and value accorded to later life. These inequalities are due to differences in status and resources of elderly and trajectories of ageing, always conditioned by social locations: position in labour market and in domestic division of labour with resulting social relations. The differences vary also between countries according to their welfare regime and their social policy. In the future, the proportion of those over 65 of age and among them of those ever 80 will be greater raises the questions of health status of the oldest generations, income distribution among generations and genders, of access to informal and formal care and adequacy of the later for the frail elderly. To cope with those issues ageing and later life should be considered in a life-span perspective. Better sharing of jobs and of economic wealth, development of meaningful activities other than work may be solutions to answer to the questions addressed by an ageing population and the problems of later life.
Factors associated with out-of-hospital coronary heart disease death: the national longitudinal mortality study.
PURPOSE: A significant portion of coronary heart disease deaths occur out of the hospital, prior to access to life saving medical care. Improving the immediacy of care could have important impact on coronary mortality. METHODS: The objective of this research is to identify factors associated with the occurrence of out-of-hospital coronary heart disease death as compared with in-hospital. Identification of these factors could lead to additional strategies for rapid treatment of coronary attack symptoms. A large national cohort study with individually identified characteristics was matched to the National Death Index to identify deaths by cause occurring in up to 11 years of follow-up. Approximately 60,000 deaths occurred in the cohort of approximately 700,000 participants aged 25 years or more. Location of death was defined as either in- or out-of-hospital. RESULTS: Among deaths classified as coronary heart disease (CHD), multivariate logistic models of the association between selected demographic and socioeconomic characteristics of individuals prior to death and place of death show that black persons are more likely to die out of hospital, as are persons who live alone or are unmarried, persons at the lowest end of the income distribution, and persons who live in rural areas vs. urban areas. CONCLUSIONS: The factors most strongly associated with a CHD death occurring out-of-hospital as compared with in-hospital are race (black persons are 1.23 times more likely to die out of hospital than white persons, net of demographic and socioeconomic differentials) and living status (persons who are not married are 1.60 times more likely to die out of hospital than persons who are married, net of demographic and socioeconomic characteristics). Attention should be paid to these groups to emphasize the need for rapid attention to the signs of a coronary attack so that rapid and potentially life saving intervention can be implemented.
A model of underlying socioeconomic vulnerability in human populations: evidence from variability in population health and implications for public health.
Drawing from insights into the variability of complex biologic systems we propose that the health of human populations reflects the interrelationship between underlying vulnerabilities (determined by population-level social and economic factors; e.g., income distribution) and capacities (determined by population-level salutary resources, e.g., social capital) and how populations, shaped by these vulnerabilities and capacities, respond to intermittent stressors (e.g., economic downturns) and protective events (e.g., introduction of a school). Monitoring this dynamic at the population-level can be accomplished by examining not only rates of illness and mortality, but variability in rates, either between populations or within populations over time. We used mortality data from New York City neighborhoods between 1990 and 2001 to test two related hypotheses consistent with this model of population health: (a) There is greater variability in mortality rates at a point in time between neighborhoods that are characterized by socioeconomic vulnerability; and (b) there is greater variability in mortality rates over time within neighborhoods that are characterized by socioeconomic vulnerability. We found that neighborhoods characterized by social and economic vulnerability displayed substantial variability in particular mortality rates. Mortality rates displaying the greatest variability were from causes that may be sensitive to social conditions (e.g., homicide or HIV/AIDS rates). Variability in population health existed both between neighborhoods with underlying vulnerability at one point in time and within vulnerable neighborhoods over time. The results of this analysis are consistent with a theory of underlying socioeconomic vulnerabilities of human populations and suggest that variability in population health may be an important consideration in population health assessment.
The wealthy get healthy, the poor get poorly? Lay perceptions of health inequalities.
Research repeatedly identifies an association between health and socio-economic status-richer people are healthier than poorer people. Richard Wilkinson has posited that socio-psychological mechanisms may be part of the explanation for the fact that socio-economic inequalities run right across the social spectrum in wealthy societies. He argues that polarised income distributions within countries have a negative impact on stress, self-esteem and social relations which, in turn, impact on physical well-being. How people experience and perceive inequalities is central to his thesis. However, relatively little empirical work has explored such lay perceptions. We attempt to address this gap by exploring how people see inequality, how they theorise its impact on health, and the extent to which they make personal and social comparisons, by drawing on 14 focus group discussions in Scotland and the north of England. Contrary to other research which suggests that people from more deprived backgrounds are more reluctant to acknowledge the effects of socio-economic deprivation, our findings demonstrate that, in some contexts at least, people from less favourable circumstances converse in a way to suggest that inequalities deeply affect their health and well-being. We discuss these findings in the light of the methodological challenges presented for pursuing such research.
Importance of baseline functional and socioeconomic factors for participation in cardiac rehabilitation.
Enrollment in cardiac rehabilitation has been reported to improve exercise capacity, psychological well-being, and survival. However, participation rates are low and the reasons for nonparticipation have not been adequately defined. The purpose of this study was to evaluate the major correlates of nonparticipation and to examine the level of participation of patients who stand to benefit most on the basis of preenrollment functional status and health behaviors. Three hundred ninety-three patients undergoing coronary artery bypass surgery (1) had baseline functional status and quality-of-life data collected, and (2) were recruited for participation in the Duke Center for Living comprehensive 3-week post-coronary bypass surgery rehabilitation program. Baseline demographic, clinical, catheterization, functional status, psychological status, and health behavior descriptors were analyzed to identify univariate and multivariable correlates of a patient's decision to participate in the program. At baseline, most clinical factors were similar in participants (n = 52) and nonparticipants (n = 341), but the nonparticipants were more often women (26% vs 12%, p = 0.02). Participants were also more likely to be employed (63% vs 45%, p = 0.02) and had a higher education and income distribution than nonparticipants (both p = 0.001). On 2 separate scales, nonparticipants had significantly more baseline functional impairment than participants (both p = 0.001). In multivariable analysis, the independent correlates of higher participation rates were: higher education (college graduates 71% more likely to participate than high school graduates) and better baseline Duke Activity Status Index (patients with mild functional impairment were at least 42% more likely to participate than patients with moderate impairment).(ABSTRACT TRUNCATED AT 250 WORDS)
Genetic testing when there is a mix of compulsory and voluntary health insurance.
When the insurer has access to information about test status, genetic insurance can handle the negative effects of genetic testing on insurance coverage and income distribution. Hence, efficient testing is promoted. When information about prevention and test status is private, two types of social inefficiencies may occur; genetic testing may not be done when it is socially efficient and genetic testing may be done although it is socially inefficient. The first type of inefficiency is shown to be likely for consumers with compulsory insurance only, while the second type of inefficiency is more likely for those who have supplemented the compulsory insurance with substantial voluntary insurance. This second type of inefficiency is more important the less effective prevention is. It is therefore a puzzle that many countries have imposed strict regulation on the genetic information insurers have access to. A reason may be that genetic insurance is not yet a political issue, and the advantage of shared genetic information is therefore not transparent.
The determinants of the public-private mix in Canadian health care expenditures: 1975-1996.
The health care policy issue regarding the balance between public and private health spending is examined. An empirical model of the determinants of the public-private mix in Canadian health care expenditures over the period 1975-1996 is estimated for total health care expenditures as well as separate expenditure categories such as hospitals, physicians and drugs. The results find that the key determinants of the split are per capita income, government transfer variables and the share of individual income held by the top quintile of the income distribution. Much of the public-private split is determined by long term economic forces. However, the importance of the federal health transfer variables and the variables representing shifts in fiscal transfer regimes suggest the increase in the private share of health spending since 1975 is also partly the result of the policy choice to reduce federal health transfers.
Deprivation and mortality: the implications of spatial autocorrelation for health resources allocation.
This paper aims at investigating whether the relationship between mortality and socio-economic deprivation is affected by the spatial autocorrelation of ecological data. A simple model is used in which mortality (all-ages and premature) is the dependent variable, and deprivation, morbidity and other socio-economic indicators are the explanatory variables. Deprivation is measured by the Townsend index; the other socio-economic variables are the median income, unequal income distribution (Gini coefficient) and population density. Morbidity is estimated on the basis of hospital admission rates and overweight prevalence. Spatial autocorrelation is measured by the Moran's I coefficient. All mortality and morbidity variables have significant, positive, and moderate-to-high spatial autocorrelation. Two multivariate models are explored: a weighted least-squares model ignoring spatial autocorrelation and a simultaneous autoregressive model. The paper concludes that spatial autocorrelation has a significant impact on the relationship between mortality and socio-economic variables. Future ecological models intended to inform health resources allocation need to pay greater attention to the spatial dimension of the data used.
The demand for alcohol in Australia.
Beers, wines and spirits differ in price, alcohol content, colour, taste and smell. These affect market demand. This paper gives an overview of consumption patterns of some broadly defined alcohol items in Australia, using data from a major household expenditure survey. Total expenditure elasticities for various alcohol items have been estimated from a new Engel function which can be called the double semi-log Engel function. Beer had the lowest elasticity, whereas the values for wine and spirits were much higher, placing them in the 'luxury' category. The percentage changes in demand due to changes in total expenditures and total expenditure inequalities were also calculated. It showed that the per capita changes in demand for beer and wine were inaccurate unless income distribution was considered. This technique can also be used to determine the level of consumption demand for various alcohol items.
Healing, medical care, and health service organizations.
This paper reviews the reasons for disappointing health results from U.S. medical care, and prescribes values for health service organizations (HSOs) that will provide a foundation for better medicine. Although the United States spends more money that any other country in the world on medical care, it ranks twenty-sixth in major indicators of population health. One reason for this is inequality in income distribution and other issues relating to social justice. Lack of access to medical care and the poor quality of care that is often rendered may also damage population health. A key component in the movement for improved medical outcomes is the concept of healing care in contrast to curing disease. Patient-centered approaches such as those advocated by the Institute of Medicine to improve medical quality and reduce medical error may provide a bridge to a healing environment in HSOs. A research program on the optimal healing environment must study issues of cost, access, and quality to support successful, broad-based integration of such programs in HSOs. Key research questions on these topics are proposed.
Racial differences in home ownership and home equity among preretirement-aged households.
This article measures the racial disparities in home ownership and home equity among preretirement-aged households. It computes the proportion of the racial gap explained by discrimination in housing and credit markets. Maximum likelihood and nonlinear least squares estimates are obtained for models of home ownership probabilities and home equity, conditional on home ownership, yielding computations for expected home equity for black and white households. The results reveal an average discriminatory gap in expected home equity as a percent of the actual gap of 55%. In the top third of the family income distribution, the measured discriminatory gap is 82%; in the middle third it is 83%; in the lowest third it is 62%.
Widening socioeconomic inequalities in US life expectancy, 1980-2000.
BACKGROUND: This study examines changes in the extent of inequalities in life expectancy at birth and other ages in the United States between 1980 and 2000 by gender and socioeconomic deprivation levels. METHODS: A factor-based deprivation index consisting of 11 education, occupation, wealth, income distribution, unemployment, poverty, and housing quality indicators was used to define deprivation deciles, which were then linked to the US mortality data at the county-level. Life expectancy estimates were developed by age, gender, and deprivation levels for three 3 year time periods: 1980-82, 1989-91, and 1998-2000. Inequalities in life expectancy were measured by the absolute difference between the least-deprived group and each of the other deprivation deciles. Slope indices of inequality for each gender and time period were calculated by regressing life expectancy estimates on deprivation levels using weighted least squares models. RESULTS: Those in less-deprived groups experienced a longer life expectancy at each age than their counterparts in more-deprived groups. In 1980-82, the overall life expectancy at birth was 2.8 years longer for the least-deprived group than for the most-deprived group (75.8 vs 73.0 years). By 1998-2000, the absolute difference in life expectancy at birth had increased to 4.5 years (79.2 vs 74.7 years). The inequality indices also showed a substantial widening of the deprivation gradient in life expectancy during the study period for both males and females. CONCLUSIONS: Between 1980 and 2000, those in higher socioeconomic groups experienced larger gains in life expectancy than those in more-deprived groups, contributing to the widening gap.
Trends in health, nutrition, and socio-economic status in Nigeria, India, and Brazil (1960-1990).
The present study compared and analysed the nutritional and economic situations in Nigeria, India, and Brazil over the three-decades between 1960 and 1990. Intra-country comparisons were undertaken for each country. The various indicators studied included among others the gross national product, total external debt, population, literacy, immunization, daily calorie intake, mortality, and life expectancy. It was noted that the economic situation influences the social and general health indicators of a country. Positive economic growth can lead to improved social development as well as diet and general health conditions. The opposite is also true, when economic growth is poor. The relationship between economic growth, and social and general health indicators is, however, not always applicable. This happens when the government fails to distribute incomes fairly; improvements in the country's social development, with nutritional and health indicators, does not occur. These findings call for a larger comparative study of the economic, social and health indicators for all the countries in the world.
Physician compensation: rewarding productivity of the knowledge worker.
Designing a physician incentive compensation plan that aligns the demands of managed care with the perceived fairness of income distribution is a key challenge for medical practices today. Rather than focus on traditional productivity measures, managed care requires physicians to demonstrate efficient practice of medicine. Physicians still need to be highly productive; however, they are now required to demonstrate efficiency related to clinical resource management, patient access and service, and evidence-based outcomes. Approaches to the development of physician incentive compensation plans and case examples are offered to assist practices that are transitioning physician compensation from volume-based to efficiency-based indicators.